NLTC Buprenorphine-Containing* Medication Induction
"Sliver" Protocol for AvoidingCommon Induction Difficulties
Induction Goal: Alleviatewithdrawal symptoms and cravings as rapidly as possible.
When to start the induction:
- Waiting for the appropriate time to start induction with this opiate replacement medication will avoid causing precipitated withdrawal. Precipitated withdrawal is a sudden increase in symptoms.
- A trial of small doses of this replacement medication is appropriateas soon as withdrawal symptoms become moderately noticeable
- Moderate withdrawal symptoms typically begin to appear 12 – 24 hoursafter an opiate is used. The interval before withdrawal symptoms appear is longer for some opiates, for example methadone and continuous release morphine sulfate(MS cont).
- Keep in mind that anxiety can be caused by something other than opiate withdrawal. Anxiety may be caused by fears about going through opiate withdrawal rather than an actual withdrawal symptom. Anxiety and fear are understandable whenever something familiar is being replaced with the unfamiliar.
Amount and Dosing Intervalsfor BuprenorphineInduction Doses
- The initial buprenorphinedose is 1– 2mg of a tablet or film strip.This amount is just asmall piece or “sliver" ofan 8mgtablet or film (or ½ of a 2mg tablet or film).
- A small "sliver"(1 – 2 mg) of medication should be placed under the tongue and allowed to dissolve.
- If withdrawal symptoms worsen after taking the initial or second dose,stop taking medication and waituntil withdrawal symptoms become even more noticeable. This may take an hour or more.
- When withdrawal symptomsbecome moderately noticeable try another "sliver" dose of medication.
- If withdrawal symptoms improve or at least do not worsen after this dose,proceed to the next step.
- Take additional 1– 2mg doses of buprenorphine approximately every 20 minutes.
- Continue repeating the small doses until you have taken 8mg. Stop taking additional doses whenever withdrawal symptoms and cravings are relieved. This may occur prior to taking 8 mgs.
- If withdrawal symptoms reappeartake additional 2–4mgdoses approximately every 20 – 60 minutes only until symptoms and cravings are relieved or a total dose of 16mg is reach.
- If withdrawal symptoms and/or cravings persist or reappear after a total dose of 16mg, take additional4mg – 8mg doses every 6 to 8 hoursuntil you reach a maximum dose of 24mg in 24 hours.
- The typical doserange for buprenorphine maintenance is 8 – 24mg per day. The correct doseis the lowest dose that controlsall withdrawal symptoms and cravings for opiates.
Using the NLTC Opiate Withdrawal Symptom Assessment Key
- Use the assessment key to evaluate and document withdrawal and craving scores.
- Assessment key scores help determine the correct time to start the induction as well as help determine the correct dose for both the induction and maintenance period.
- Complete instructions for use are provided on the key.
Notes on preparing and taking induction medication doses: When dividing buprenorphine into 1 mg – 2 mg sized doses for induction do so over a clean piece of paper. Retain all pieces (even powder) created by dividing the tablets or film strips to be used for induction doses. Buprenorphine should not be swallowed. Buprenorphine-containing medication should always be placed under the tongue and allowed to slowly and completely dissolve. Film strips dissolve relatively quickly while tablets typically dissolve in 5 – 10 minutes.
*The term buprenorphine is interchangeable with all formulations of this medication including Suboxone®
revised 9/13